Every finding on record at Florence Nursing Home

Based on observation, interview, and record review the facility failed to transfer a resident in a safe manner. This applies to one of two residents (R13) reviewed for safety in the sample of 23. The findings include: The face sheet for R13 shows she was admitted to the facility with diagnoses to include Alzheimer's, hypertension and muscle weakness. The facility assessment dated [DATE] shows her to have severe cognitive impairment and requires maximum staff assistance with transfers. On 5/6/2025 at 9:12 AM, R13 was observed being transferred from her wheelchair to her bed by V3 Certified Nursing Assistant (CNA). V3 who was wearing a gait belt around her waist, lifted R13 up from her wheelchair by placing her arms under R13's arms, pivoted her to the bed and lowered her onto her bed. On 5/7/2025 at 1:52 PM, V3 said a gait belt should have been used to transfer R13 from the chair to her bed. On 5/7/2025 at 1:48 PM, V2 Director of Nursing (DON) said a gait belt should always be used during a transfer for the safety of the resident and the staff. The undated facility gait belt policy shows to assure the safety of the residents and staff when assisting with a transfer or ambulation a gait belt will be used. 2. All residents who require assist with transfers and do not require an electric lift will utilize a gait belt with all transfers unless contraindicated.

Based on observation, interview, and record review the facility failed to provide incontinence care in a manner to prevent cross-contamination for 2 of 3 residents (R1, R23) reviewed for infection control in the sample of 23. The findings include: 1. On 5/6/25 at 9:34 AM, V3 and V4 (Certified Nursing Assistants - CNAs) used a total mechanical lift to transfer R1 into bed. They turned R1 side to side to removed the sling. V4 (CNA) opened R1's incontinence brief to provide care. V4 said R1's brief was wet and used wipes to cleanse the urine from R1's perineal area. V4 used the same (contaminated) gloves to obtain a clean brief and remove R1's glasses. Then V4 used a wipe to clean R1's bottom, applied barrier cream, turned R1 and closed the clean brief. V4 covered R1 with a blanket. V4 was wearing the same contaminated gloves throughout the observation. R1's Facesheet dated 5/8/25 showed R1 had diagnoses to include, but not limited to: osteoarthritis, palmar facial fibromatosis, Alzheimer's Disease, hypertension, contracture of her left hand, diarrhea, and mixed obsessional thoughts and acts. R1's facility assessment dated [DATE] showed she had severe cognitive impairment; required substantial to maximal staff assistance for personal hygiene; was dependent on staff for toileting, transfers, and bed mobility; and was always incontinent of bowel and bladder. V1 said V4 should not have worn the same gloves throughout R1's incontinence care due to the risk of cross-contamination. V1 said V4 should have changed her gloves and performed hand hygiene when moving from dirty to clean tasks. V1 said there will be in-services for this. The facility's Incontinence Policy dated 2024 showed, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services . The facility's Personal Protective Equipment - Using Gloves Policy dated 2010 showed, Purpose: To guide use of gloves. Objectives: 1. To prevent the spread of infection . Miscellaneous . 4. Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces. 5. Wash hands after removing gloves . 2. On 5/6/25 at 10:12 AM, V4 (CNA) and V5 (Hospice Nurse) transferred R23 to bed using a mechanical lift. V4 and V5 rolled R23 side to side to remove the lift sling. V4 (CNA) opened R23's incontinence brief and said it was wet. V4 threw the soiled incontinence brief at the foot of R23's bed. The brief was opened and landed on R23's bed linens. V4 provided incontinence care and applied barrier cream to R23's bottom before changing her gloves. V4 applied a clean brief, covered R23, and removed the soiled brief from R23's bed linens. R23's Facesheet dated 5/8/25 showed diagnoses to included, but not limited to: diabetes, stroke with right sided weakness, Chronic Obstructive Pulmonary Disease (COPD), hypothyroidism, mild protein-calorie malnutrition, and a history of C. diff (Clostridium difficile colitis - inflammation of the colon caused by a bacteria) and urinary tract infections. R23's facility assessment showed she had severe cognitive impairment; was dependent on staff for personal hygiene, toileting, transfers, and bed mobility; and was always incontinent of bowel and bladder. On 5/8/25 at 10:28 AM, V1 (Administrator) said she is the Infection Preventionist for the facility and she takes that role very seriously. V1 said V4 has been a CNA for a long time. The surveyor asked V1 if a soiled incontinence brief should be thrown at the foot of the resident's bed. V1 replied, Absolutely not, the soiled brief should be placed in a trash bag and not contact the resident's bedding. It's a cross-contamination risk.

Based on observation, interview, and record review the facility failed to implement an Enhanced Barrier Precautions Procedure which applies to all 30 residents in the facility. The findings include: The federal form 671 completed by the facility on 4/1/24 showed the facility census was 30 residents. On 4/1/24 the facility had no Enhanced Barrier Precautions (EBP) signs up or Personal Protective Equipment (PPE) carts out for EBP residents. The facility's EBP list dated 4/1/24 showed R13, R16, and R26 had feeding tubes. R3, R23, R30, and R83 had indwelling urine catheters. R3 also has a daily wound dressing change. On 4/1/24 at 11:20 AM, V6 and V10 Certified Nursing Assistants (CNAs) provided incontinence care to R16 without wearing PPE gowns during care. No EBP sign was noted on the door at that time. On 4/1/24 at 11:58 AM, V6 and V10 provided peri care for R3. At that time, V5 Licensed Practical Nurse entered R3's room to provide wound care. V5, V6, and V10 did not wear gowns while providing cares for R3. No EBP sign was posted at the time of the cares. On 4/2/24 at 8:50 AM, V9 Registered Nurse said they had not received any education prior to 4/2/24 in regards to EBP. On 4/2/24 at 1:00 PM, V1 Administrator said the facility did not utilize EBP prior to the 4/1/24 implementation date. V1 stated, We do not have a EBP procedure in place at this time. We have a policy and staff education which will be in place by 4/8/24. On 4/3/24 at 9:56 AM, V2 Director of Nursing stated, We will be educating staff on EBP procedures for PPE for residents who should be on EBP. We did not have procedures in place on 4/1/24. The facility's Enhanced Barrier Precautions Policy revised on 4/1/24 showed residents with indwelling medical devices should be on EBP. This Policy showed medical devices include: central lines, urinary catheters, feeding tubes, and tracheotomy/ventilator tubes.

Based on interview and record review, the facility failed to safely perform ADL (Activities of Daily Living) assistance for one of 12 residents (R21) reviewed for safety in the sample of 12. The findings include: R21's Transfer/Discharge Report dated April 3, 2023 shows R21 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, muscle wasting and atrophy, cognitive communication deficit, fall, morbid obesity, and dementia. R21's Care Plan shows R21 requires extensive assistance by two staff to turn and reposition in bed. R21's Monthly Nursing Screen dated December 19, 2023 shows R21 requires extensive assistance with two staff members for bed mobility. R21's Progress Note dated December 23, 2023 at 5:45 AM shows, the nurse was told by CNA (Certified Nursing Assistant) R21 had a fall and had two skin tears. R21's right elbow and left forearm had a skin tear. R21 had a large knot on his forehead. 911 was called, the paramedics came. R21's Progress Note dated December 23, 2023 at 10:15 AM, shows R21 returned to the facility with a head contusion noted to the right side. R21 was alert to his name and able to verbalize that he fell this morning and hurt his head. The facility Incident/Accident Report dated December 23, 2023 shows, CNA reported resident had fallen from the bed during cares. This writer assessed resident and found skin tear to left forearm, right elbow, left knee abrasion, redness to right forehead. Cat scan head and neck no abnormalities, CNA counseled, staff in-serviced. On April 3, 2024 at 9:43 AM, V2 DON (Director of Nursing) said that V7 CNA was performing cares and getting R21 ready for the morning. V2 said that R21 was rolled onto his side when V7 went to grab washcloths and R21 rolled out of the bed. V2 said the bed was elevated and there was no floor mats in place because V7 was performing cares. V2 said that V7 was performing cares on R21 by himself. Two attempts were made to interview V7 (R21's CNA) and V8 (R21's nurse) on April 3, 2024 unsuccessfully. The facility's Safe Resident Handling/Transfers policy dated 2023 shows, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Resident lifting and transferred will be performed according to the resident's individual plan of care.

Based on observation, interview, and record review, the facility failed to have pressure relieving devices in place for one of one resident (R3) with high risk of pressure injuries in the sample of 12. The findings include: R3's Transfer Discharge report dated April 1, 2024 shows R3 was admitted to the facility on [DATE] with diagnoses including acquired absence of right foot, pressure injury of left heel, and congestive heart failure. R3's Care Plan shows R3 has potential for pressure injury development related to peripheral vascular disease, advanced age, poor safety awareness, and chronic pain. Follow facility policies/protocols for the prevention/treatment of skin breakdown. R3's Scale for Predicting Pressure Injury Risk for that R3 has a moderate risk for developing pressure injuries. R3's Wound Weekly Observation Tool dated March 20, 2024 shows that R3 had a pressure injury to his coccyx that healed. R3's Wound Weekly Observation Tool dated April 1, 2024 shows that R3 developed a stage II pressure injury to his coccyx. R3 Wound Weekly Observation Tool dated March 27, 2024 shows that R3 has a wound to his left heel. Special equipment/Preventative Measures include air mattress and foot protectors. R3's Treatment Medications dated March 1, 2024-March 31, 2024 shows an order for prevalon boot-continue to wear at all times. On April 1, 2024 at 9:16 AM, R3 was laying in bed. There was a heel boot noted to his night stand next to the head of his bed. R3 was laying on his left side with his left foot directly on the bed. At 11:58 AM, V6 and V10 CNAs (Certified Nursing Assistants) performed peri care to R3. There was an air mattress pump at the foot of R3's bed that was not buzzing, nor were there any lights on to indicate the air mattress was on. R3's heel boot was still on the night stand. R3's left foot had a dressing present. There was a small open area noted to R3's coccyx. At 2:24 PM, V5 LPN (Licensed Practical Nurse) came into R3's room. The air mattress pump at the foot of R3's bed still had no on indicator lights on. There was a medical grade surge protector at the head of R3's bed. The plug of the air mattress was halfway out of the outlet. V5 pushed the plug in and a green light turned on on the pump. V5 said the air mattress was off. On April 3, 2024 at 10:22 AM, V5 said that R3 should have foot protection on and an air mattress. V5 said if the air mattress is off, then the mattress will deflate. V5 said the light on the pump is green when the mattress is turned on. The facility's Pressure Injury Prevention Guidelines dated June 1, 2023 shows Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assess at risk or who have a pressure injury present. Interventions will be implemented in accordance with physician order, including the type of prevention devices to be used and, for tasks, the frequency for performing them. Prevention devices will be utilized in accordance with manufacturer recommendation (e.g., heel flotation devices, cushions, mattresses).

Based on interview and record review, the facility failed to notify a resident's legal representative of a change in condition for 1 of 3 residents (R1) reviewed for notification in the sample of 6. The findings include: R1's Illinois Statutory Short Form Power of Attorney for Health Care (POAHC) shows R1 designated V6 as her legal POAHC on 6/6/2017. R1's IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form dated 8/7/21 shows V6 signed as R1's legal representative. R1's Incident/Accident Report dated 10/13/23 shows V3 (Licensed Practical Nurse/LPN) notified V7 (R1's son) when R1 was found on the floor in her room. R1's Admission Record (Face Sheet) dated 8/1/23 shows R1's first emergency contact is V6. On 1/2/23 at 10:26 AM, V3 said she notified V7 (R1's son) when R1 was found on the floor and planned to send R1 to the hospital. V3 said she notified V7 and not V6 because V7 was the first emergency contact, and he knew more about R1. V3 said V7 would tell them to notify him first for everything regarding R1 and he would notify the rest of the family. On 1/2/23 at 11:23 AM, V2 (Director of Nursing) said the POAHC is always the first person to contact in the event of a resident fall or other change in condition. V2 said the POAHC is determined by the advanced directive paperwork. V2 said they would notify the POAHC quite rapidly after an incident and would not wait a day. On 1/2/23 at 12:53 PM, V1 (Administrator) said Social Services goes through the resident's legal papers and puts the information on the resident's Face Sheet so staff know who the POAHC is for them to contact that person with any changes or concerns regarding the resident. V1 said V6 is the POAHC for R1. On 1/2/23 at 10:52 AM, V4 (Registered Nurse) said she will contact the resident's POAHC for any changes in a resident's condition. V4 said the POAHC is listed on the resident's Face Sheet. V4 said she would only contact the POAHC for privacy. V4 said the POAHC can inform any further family members. The facility's Notification of Physician and Responsible Party for Resident Condition Change Policy (undated) shows the resident's responsible party is to be informed in the event of an accident involving the resident.

Based on interview and record review the facility failed to offer and administer pneumonia vaccines (pneumococcal conjugate vaccine [PCV15] and Pneumococcal polysaccharide vaccine [PPSV23]) for 2 of 5 residents (R6 and R29) reviewed for vaccines in the sample of 12. The findings include: 1. R6's face sheet shows R6 is [AGE] years old and was admitted to the facility on [DATE]. R6's Immunization Report provided on 5/16/2023 showed R6 received the PCV13 (pneumococcal conjugate vaccine [PCV13] vaccine on 9/22/2017 and did not receive the PPSV23 vaccine. On 5/17/2023 at 9:00 AM, V2 (Director of Nurses) said that R6 was not offered the second dose of the pneumonia vaccine. V2 believed that there should be five years between administration of the PCV13 vaccine and the PPSV23 vaccine. 2. R29's face sheet shows R29 is [AGE] years old and was admitted to the facility on [DATE]. R29's Immunization Report provided on 5/16/2023 showed R29 received the PCV13 vaccine on 8/13/2019 and did not receive the PPSV23 vaccine. On 5/16/2023 at 3:07 PM, V2 provided a signed pneumonia vaccine consent form for R29 dated on 3/31/2023. V2 said the vaccine was ordered from the pharmacy but no additional follow up was done to provide the consented vaccination to R29. On 5/16/2023 at 1:43 PM, V2 said the pneumonia vaccine is offered upon admission and they will use the Centers for Disease Control and Prevention (CDC) guidelines along with the resident's health records to offer and provide the correct sequence of pneumonia vaccines depending on the age of the resident. The facility's Vaccine Information Statement (no date) provided to residents with the pneumococcal vaccine states, . Adults [AGE] years who have not already received a pneumococcal conjugate vaccine should receive either: a single dose of PCV15 followed by a dose of PPSV23, or a single dose of PCV20. The facility's Pneumococcal Disease Prevention Policy revised 7/2022 states, In order to reduce the disease-morbidity and mortality associated with pneumococcal disease, pneumococcal vaccines are offered to all residents. Procedures: . B. Nurse will use CDC PneumoRecs Vax Recommendation to verify correct Pneumonia Vaccine needed. C. Residents will be offered a pneumococcal vaccine (such as the pneumococcal conjugate vaccine PCV15 or PCV20) in accordance with the CDC recommended immunization schedule .

Based on observation, interview, and record review the facility failed to handle ready to eat foods according to professional food safety standards. This applies to 2 (R12 and R13) of 12 residents reviewed for food safety in the sample of 12. The findings include: On 5/15/2023 at 12:15 PM, V3 (Dietary Manager) requested bread for R12 and R13 from V4 (Cook). V4 reached into the bread package without gloves, grabbed two slices of bread, and placed them into a plastic bag. V3 served the bread to R12 and R13. On 5/15/2023 at 12:20 PM, V3 said that gloves should be used to serve bread and other ready to eat foods. Facility Bare Hand Contact with Ready-To-Eat Foods policy (no date) states, The Food Service Sanitation Rules & Regulations state that food employees cannot handle ready-to-eat foods with their bare hands. Ready-to-eat foods are foods that will be consumed without additional washing, cooking, or preparation. What are some examples of ready-to-eat foods? Fresh fruits and vegetables served raw, bread, toast, rolls, and baked goods .

Based on observation, interview, and record review the facility failed to ensure a resident's oral appliance was applied correctly for a resident who requires extensive assist with personal hygiene/oral care. This applies to 1 of 12 (R29) residents reviewed for activities of daily living in the sample 12. The findings include: R29's face sheet shows she is an [AGE] year-old with diagnosis including bilateral osteoarthritis of first carpometacarpal joints, hemiplegia affecting left and right side, and contractures to left and right hand. R29's Minimum Data Sheet assessment dated [DATE] shows she requires extensive assist with transfers, personal hygiene, eating, and has limited range of motion to both upper extremities. On 5/15/23 at 12:50 PM, R29 was in the dining room during the noon meal. She was served chopped pot roast, potatoes, and broccoli. V6 (Certified Nursing Assistant/CNA) was feeding R29 her noon meal. R29 said to V6 something is stuck in the back of my throat, it's scaring me. V6 wheeled R29 to her room. V6 said R29 reported the glue from her dentures is stuck in her mouth. V6 asked R29 to open her mouth and the adhesive from her top dentures was oozing out from the back of her upper palate. A clump of adhesive was removed from the back of her tongue. V6 stated, Oh my gosh, a lot was in there. V6 removed R29's dentures and removed another round globe of adhesive. V5 (Licensed Practical Nurse) entered the room with a mouth swab and removed two additional chunks of adhesive from R29's mouth. R29 said when the staff put in her dentures and pressed down the glue was coming out, they used too much glue, it was all over my tongue, It's scary. On 5/15/23 at 1:50 PM, V6 (CNA) said staff apply R29's dentures because she cannot use her hands. Whoever put on her dentures put too much adhesive. V6 said she did not apply R29's dentures. On 5/15/23 at 2:08 PM, V2 (Director of Nursing) said R29 had an excessive amount of adhesive in her mouth, and it was uncomfortable for her. She explained to the staff when applying the adhesive to place four small pea size amounts on the dentures and it will expand when you apply it to the gums securing it in place. R29's current care plan shows she has a self-care performance deficit related to osteoporosis and the unable to use her bilateral upper extremities with interventions for staff to assist her personal hygiene and oral care. The facility's Care of Dentures Policy dated May 2023, states, 1. Determine which nursing staff member will provide denture care. It is usually the nurse aide assigned to the resident .11. Some residents use an adhesive to seal dentures in place. Apply a thin layer to undersurface before inserting. 12. If the residents needs help inserting the dentures, moisten upper dentures and press firmly to seal it in place. Ask the resident if dentures feel comfortable.

Based on observation, interview, and record review the facility failed to ensure the chemical sanitation levels of the dishwasher were consistently checked and documented; failed to ensure pears were covered in the refrigerator; and failed to ensure food and drinks were covered when transported to resident rooms. These failures have the potential to affect all the residents in the facility. The findings include: The CMS-672 dated 6/29/22 showed 33 residents resided in the facility. 1. On 6/28/22 at 9:55 AM, V8 (Dietary Aide) tested the chlorine level of the dishwasher. V8 said the heater is getting fixed, so we only check the chlorine level right now. The chlorine level should be checked before breakfast, lunch, and dinner dishes. The person checking the chlorine levels should initial that it was checked. V8 said he wasn't sure why the sanitation logs were not consistently filled out. I see that some people are signing off on the temperature and we aren't testing that. I guess they are just initialing it was done. There should be initials under the chlorine check three times a day. There should not be any blanks. On 6/28/22 at 10 AM, V9 (Dietary Manger) said the facility has a new heater for the dishwasher but is waiting for one more part to get the heater connected. V9 said the dietary aides should check the chlorine level three times a day and write it on the Chemical Sanitation Log, but they are not checking the temperature at this time. This surveyor reviewed the Chemical Sanitation Log with V9. V9 stated, I see why it's confusing. Some of the staff are initialing under the temperature and we aren't even checking that. A blank box means that the chemical level wasn't checked. This log is a mess. It's hard to follow what they are checking. The facility's Chemical Sanitation logs dated 5/22 - 6/28/22 showed blank boxes under the chlorine level check for all the breakfast shifts. The chlorine level check for the lunch shift was blank on 6/24 and 6/25. The chlorine level check for dinner shift was blank 6/1 - 6/26. 2. On 6/28/22 at 10:04 AM, V9 (Dietary Manager) opened the reach in refrigerator. There was a large tray containing individual bowls of pears. These bowls were not covered. V9 said food should be covered to keep anything from getting in the food. V9 stated, I didn't cover those because they are for lunch. If I would have prepared them for the next day, then I would have covered them. The facility's undated Food Storage Policy showed, .Food in the refrigerator will be covered, labeled and dated . 3. On 6/28/22 at 12:24 PM, V10 (Licensed Practical Nurse)prepared plates for R134, R28, R12, and R133. V10 handed each plate to V8 (Dietary Aide). V8 placed the plate on the tray and covered the plate with a plastic cover. Each tray had a bowl of pears that were uncovered and beverages that were uncovered. V8 loaded these trays onto an open cart, walked through the West dining room and dropped off the cart on the West hallway. The open cart sat in the hallway as residents and staff passed by. V10 pushed the uncovered cart with the uncovered pears and drinks down the hall delivering trays to R134, R28, R12, and R133. On 6/28/22 at 3:32 PM, V9 (Dietary Manager) said food should be covered when it is taken into the hallway. We always cover the plate. We don't usually cover the dessert or the drinks. We have small pieces of plastic wrap, so I could cover them. The food should be covered to prevent anything from getting into it. On 6/29/22 at 8:30 AM, the uncovered cart was sitting in the West hallway with breakfast trays for R32, R133, and R12. All the beverages were uncovered. The staff were transporting residents to the dining room past uncovered beverages on the cart. V11 (Certified Nursing Assistant/Social Services) pushed the cart down the hall and began delivering the trays to the room. On 6/30/22 at 8:39 AM, V11 (CNA/SS) said that all the staff assist with mealtimes. V11 said the dietary aide will bring the room trays to the hall, on a cart. The cart doesn't have a cover on it. V11 said dietary will deliver R134's tray to his room and we will the deliver the other trays. V11 said the drinks and desserts aren't usually covered on the room trays. The facility did not have a policy regarding room tray service.

Based on observation, interview, and record review, the facility failed to position a urinary drainage bag in a manner to prevent urinary tract infections for 1 resident (R3) and failed to ensure a resident's catheter bag and tubing remained off the floor for 1 resident (R31). These failures apply to 2 of 2 residents reviewed for urinary catheters in the sample of 14. The findings include: 1) R3's electronic face sheet printed on 6/30/22 showed R3 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's facility assessment dated [DATE] showed R3 has severe cognitive impairment and has an indwelling catheter. R3's care plan dated 5/4/21 showed, (R3) has indwelling catheter due to left hydrocele, bilateral hydronephrosis and hydroureter. Position catheter bag and tubing below the level of the bladder. On 6/28/22 at 11:07AM, V11 and V12 (Certified Nursing Assistants) were providing transfer assistance for R3. V12 placed R3's urinary catheter drainage bag on top of his stomach during the mechanical lift transfer. Urine was seen back flowing into the tubing towards R3's catheter insertion site. V11 stated the urinary catheter bag should be kept below the level of the resident's bladder to prevent back flowing of urine and prevention of urinary tract infections. On 6/29/22 at 1:34PM, V3 (Registered Nurse) stated, All residents with a urinary catheter should have the drainage bag kept below the level of their bladder. We do this to prevent backflow of urine and prevent urinary tract infections. On 6/30/22 at 9:36AM, V2 (Director of Nursing) stated, Urinary catheter bags should be positioned below the level of the bladder to prevent backflow and urinary tract infections. During a mechanical lift transfer, one of the staff members would be holding the bag below the level of the bladder for proper positioning. The facility's undated policy titled, Catheter-Suprapubic Care showed, Purpose: To prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract .3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent urine in the tubing and drainage bag from flowing back into the urinary bladder. 2) R31's face sheet printed 6/30/22 showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's June 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R31's progress note dated 6/12/22 showed R31 was sent to the local emergency room with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/22 at 12:30 PM, V5 (Certified Nurse Assistant) propelled R31 in his wheelchair out of his room and to the group dining room for lunch. R31's catheter bag and tubing were dragging on the floor down the hall and into the dining room. At 12:57 PM, V2 (Director of Nurses) raised the catheter bag and tubing higher under the wheelchair and propelled the resident back to his room. On 6/29/22 at 8:48 AM, R31 was seated in his wheelchair in the group dining room for breakfast. The catheter bag and tubing were lying directly on the floor. At 12:41 PM, R31 was seated in his wheelchair in the group dining room for lunch. The catheter bag and tubing were lying directly on the floor. On 6/30/22 at 9:53 AM, V2 (DON) stated it is an infection control problem for catheter bags or tubing to be in direct contact with the floor. Germs can get introduced into the resident and cause a urinary tract infection. They should be off the floor at all times and staff should be looking for the positioning before transporting a resident. The facility's undated Foley Catheter policy states: Never allow the bag to touch the floor, it if does it needs to be replaced.

Based on observation, interview, and record review the facility failed to ensure a treatment dressing was in place for one of one resident (R31) reviewed for pressure ulcers in the sample of 14. The findings include: R31's face sheet printed 6/30/22 showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's facility assessment dated [DATE] showed extensive staff assistance required for bed mobility, transfers, locomotion, dressing, and toilet use. The assessment also showed R31 is occasionally incontinent of urine and bowel. R31's weekly wound observation report dated 6/29/22 showed a coccyx (lower back) pressure ulcer measuring 1.5 cm (centimeter) long x 0.5 cm wide x 1 cm deep. The report showed R31 was admitted with the wound at a stage 2. R31's June 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/22 at 1:23 PM, V3 (Registered Nurse) stated R31 came back from a hospital stay a few weeks ago and had a pressure ulcer to his coccyx. V3 said he had a wound consultation with the wound nurse practitioner. Orders for dressing changes and treatments were obtained. V3 said the floor nurses do the wound treatments and dressing changes, unless the wound nurse is there for the weekly assessment. On 6/29/22 at 2:33 PM, V6 and V7 (Certified Nurse Assistants/CNA) transferred R31 into bed and removed his brief to provide incontinence care. R31 was rolled to his side and a large, open lemon-sized pressure ulcer was visible on his coccyx (lower back). V6 and V7 verified there was no dressing in the brief. V4 (Licensed Practical Nurse) was also at the bed side and observed the uncovered pressure ulcer. V4 said the area always needs a dressing on it. It must have come off and no one reported it. V4 said the dressing keeps any bowel movement from entering the site. V4 said the wound could get infected and spread through his system if germs enter that area. V4 said the dressing also helps keep the (Brand name treatment) on the site and that helps heal the area. V6 (CNA) stated missing dressings should be reported right away to the nurse. It is important to get it covered in order to help it heal and stop any infection. On 6/30/22 at 9:56 AM, V2 (Director of Nurses) stated an uncovered pressure ulcer can cause further breakdown. Following physician treatment orders are important for healing and to prevent infection. The coccyx dressing is important to protect the wound from a highly dirty area. It helps keep urine and bowel out of the wound. The aides should be immediately alerting the nurses, so dressings get replaced. Leaving them open reduces the healing process. The facility Management of Wounds policy revision dated 10/16/15 states under the providing local wound care section: It is the policy of this facility to treat wounds according to the guidelines of the Agency for Healthcare Research and Quality (AHRQ), National Pressure Advisory Panel (NPUAP), and current standards of clinical practice.

Based on observation, interview, and record review the facility failed to ensure safety alarms were operational for one of five residents (R31) reviewed for safety and supervision in the sample of 14. The findings include: R31's face sheet printed 6/30/22 showed diagnoses including but not limited to right side paralysis, arthritis, [CONDITION(S)], kidney disease, and retention of urine. R31's facility assessment dated [DATE] showed extensive staff assistance required for bed mobility, transfers, locomotion, dressing, and toilet use. The assessment also showed R31 is occasionally incontinent of urine and bowel. R31's fall risk assessment dated [DATE] showed a high risk for falls. R31's progress note dated 6/10/22 stated staff was called to his room upon hearing the bed alarm going off and the resident attempting to transfer out of the bed without staff assistance. R31's June 2022 physician order sheet showed an order for safety devices including a bed alarm and a chair alarm. On 6/28/22 at 11:06 AM, R31 was lying in bed and covered up with his blankets. No staff were present in the room. R31 had a bed alarm attached to the bed. The alarm box was lying on his bedside table and no indicator lights were flashing. A wheelchair was next to his bed and a chair alarm was hooked on the back handle. There were no wires or seat pad attached to the chair alarm box. At 1:10 PM, V5 (Certified Nurse Assistant) transferred R31 from his wheelchair to the bed. The chair alarm was still on the back of his wheelchair and there was no safety pad attached to the alarm box. V5 assisted R31 to a standing position. No alarm sounded when R31 stood up. V5 was questioned about the alarm box on the wheelchair and stated she did not know why there was not any safety pad plugged into the alarm box. V5 was questioned now do the aides know alarms are working correctly and stated a green light blink on the front to show it is in use. V5 said the chair and bed alarms both work the same way. V5 said R31 needs the bed alarm on at all times when he is in bed. On 6/28/22 at 12:45 PM, R31 was seated in his wheelchair in the group dining room. At 1:05 PM, R31 was seated in his wheelchair and alone in his room. R31's chair alarm was not operating at either observation. On 6/29/22 at 8:48 AM, R31 was seated in his wheelchair in the group dining room. At 12:41 PM, R31 was seated in his wheelchair in the group dining room. At 1:23 PM, R31 was seated in his wheelchair and alone in his room. R31's chair alarm was not operating at any of the observations. On 6/29/22 at 9:55 AM, V4 (Licensed Practical Nurse) stated R31 does attempt to get out of bed by himself. He is slightly confused and will try to stand by himself. He has a chair and bed alarm to alert staff he is attempting to get up alone. On 6/30/22 at 8:57 AM, R31 was lying in bed and alone in his room. R31's bed alarm was not operating. At 9:00 AM, V2 (Director of Nurses) was shown the bed alarm box and stated the box is not on. V2 said R31 needs the alarms on when he is in the wheelchair or in bed. V2 said the alarms alert us that he is getting up without assistance. If they are not working correctly, residents can have an increased risk of falls and a high potential for injury. The facility Body Alarm policy dated 8/5 states: 4. Staff will report to charge nurse of any problems with the body alarm; if it is missing, not functioning, or if resident refuses to wear it. 6. Check all body alarms in the beginning of each shift to make (sure) they are working properly.

Based on observation, interview, and record review the facility failed to ensure a resident window blind was closed during perineal care for 1 of 1 resident (R8) reviewed for privacy in the sample of 13. The findings include: R8's transfer/discharge report printed on 8/19/21 showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's facility assessment dated [DATE] showed no cognitive impairment and the need for extensive assistance of two for dressing, toilet use, and personal hygiene. The assessment also showed R8 is always incontinent of bowel and bladder. On 8/17/21 at 11:35 AM, V9 (CNA-Certified Nurse Aide) provided incontinence care to R8 while she was lying in bed. R8's bed was directly next to the outside window and the blind was completely open. V9 removed R8's wet adult brief and cleansed her groin area. V9 rolled R8 to the left side, cleansed her back side and rolled her to the right side to put a clean brief on. R8 was completely naked from the waist down during the personal care. R8's window was open to the facility parking lot and faced a neighboring private resident home across from the parking lot. At 11:48 AM, V11 (CNA) and V9 used a mechanical lift to transfer R8 from her bed into her wheelchair. R8's window blind was still wide open. On 8/19/21 at 10:42 AM, V10 (CNA) said staff should always give privacy to residents while providing personal care. We should close the room door, pull the curtain between residents, and close the window blinds. It is a dignity and privacy thing. We would not want to be seen naked, so why would we expect a resident to want to be seen that way? On 8/19/21 at 10:49 AM, V2 (Director of Nurses) stated privacy is important during all resident care. CNAs should knock, introduce themselves, close the curtain, and the window shade. The window shades should be closed to be sure outside people can't see into resident rooms. Residents would not like that, and the person outside would probably not like that either. V2 said every resident receives a copy of the resident right booklet at admission and privacy is discussed in there. On 8/19/21 at 10:52 AM, V9 (CNA) stated, Yes, thinking back to that day, we should have closed the curtain. It is important to do for resident privacy. The undated Residents Rights for People in Long-Term Care Facilities pamphlet (Produced by the Illinois Department of Aging) states: Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care. The facility's Resident Rights Guidelines for All Nursing Procedures policy revision dated 10/2010 states: f. Close the room entrance door and provide for the resident's privacy.

Based on observation, interview, and record review the facility failed to ensure a contract was obtained with the [CONDITION(S)] center and failed to ensure a resident dependent on [CONDITION(S)] treatment was monitored and managed for 1 of 1 resident (R19) reviewed for [CONDITION(S)] services in the sample of 13. The findings include: R19's medical record showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The only documentation found on R19's TAR related to [CONDITION(S)] was, Site: Lt (Left) upper arm (5/27/20) Remove bandaid after [CONDITION(S)] on M-W-F at 3-11 PM. R19's care plan initiated on 2/25/20 showed, [R19] needs [CONDITION(S)] every Monday, Wednesday, and Friday related to renal failure (Occasionally an extra day during the week depending on fluid.) Interventions: Monitor/document/report PRN (as needed) for signs and symptoms of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. On 8/19/21 at 10:23 AM, V4 LPN (Licensed Practical Nurse) said R19 goes to [CONDITION(S)] on Monday, Wednesday, and Friday and comes back with a pressure dressing that is taken off on second shift. R19 said the facility communication with the [CONDITION(S)] center is done through faxes back and forth if there are any new orders. R19 was unsure what type of [CONDITION(S)] R19 had for sure. V4 was unsure what the thrill and bruit would be related to R19's [CONDITION(S)] site. R19 said the nurses do not have to do anything with R19's fistula aside from removing the bandage when she comes back from the treatment. On 8/19/21 at 10:30 AM, V2 DON (Director of Nursing) said the nurses do not have any monitoring to do of R19's [CONDITION(S)] site. V2 said there is no communication forms or consistent communication between the facility and the [CONDITION(S)] center. V2 said there are just faxes that will get sent back and forth if something changes in R19's care. On 8/19/21 at 11:30 AM, V1 Administration said they have not signed a contract with the [CONDITION(S)] center at this time but that it is in progress. The facility's undated policy titled [CONDITION(S)] Management (Hemodialysis) showed, . 1. Purpose, To implement processes to promote the comfort, safety and management of hemodialysis residents . 2. Contractual agreement will include but may not be limited to the following, a. Medical and non-medical emergencies .c. Interchange of information useful/necessary for the care of the resident. d. Identifying roles and responsibilities between the facility and the [CONDITION(S)] center. e. Coordination regarding medication administration 3. Clinical Responsibilities will include but are not limited to the following a. Assessment and documentation of fistula or graft site upon returning from [CONDITION(S)] and prn. b. Documentation of post [CONDITION(S)] weights as determined by the interdisciplinary team in collaboration with the [CONDITION(S)] center

Based on observation, interview, and record review the facility failed to provide incontinence care in a manner to prevent cross contamination for 1 of 1 resident (R16) reviewed for incontinence care in the sample of 13. The findings include: R16's medical record showed he was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's facility assessment dated [DATE] showed he is dependent upon staff for all cares. R16's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/19/21 at 9:40 AM, V8 and V10 CNA (Certified Nursing Assistants) were providing incontinence care and catheter care for R16. V8 was using a soapy washcloth and washed R16's peri area and down the catheter tubing. V8 and V10 then rolled R16 over and wiped his buttocks. V8 and V10 rolled R16 back onto his back and without changing gloves started wiping R16's peri area with a clean towel. On 8/19/21 at 12:11 PM, V2 DON (Director of Nursing) said gloves should be changed whenever going from a clean to a dirty. V2 said V8 should have changed her gloves after wiping R16's buttocks and before wiping R16's peri area again. The facility's policy for changing gloves during incontinence care was requested and not received. The facility's policy revised March 2004 for Using Gloves showed, . The purpose of this procedure is to provide guidelines for the use of gloves. Objectives, 1. To prevent the spread of infection and disease to residents and employees; .

Based on observation, interview, and record review the facility failed to properly sanitize food preparation equipment. This applies to 6 of 6 residents (R6, R23, R28, R31, R32, & R234) in the sample of 13. The findings include: On 10/13/2020 at 10:00 AM, V5 Cook was preparing pureed meals for R6, R23, R28, R31, R32, & R234. V5 first prepared pureed turkey then cleaned the blender components in soapy water then in a sink with quaternary (disinfectant). V5 tested the quaternary level in the sink and the color of the strip was more orange than green. A color shift from orange to light green/brown indicates a level of 150 parts per million (ppm). The color of the test strip indicated a level less than 150 ppm. After the blender dried, V5 then proceeded to use the blender to puree the mixed vegetables. On 10/13/20 at 10:00 AM, V5 stated I shoot for 150-200 (ppm quaternary). On 10/13/20 at 1:52 PM, V3 Dietary Manager stated the quaternary level should be 200 ppm. V3 said quaternary is a disinfectant used to kill bacteria and pathogens. The facility's policy for Two Compartment sink showed, Take chemical testing strip and make sure it reaches 200 on the guide. The facility provided resident roster showed R6, R23, R28, R31, R32, & R234 received the pureed meal on 10/13/2020.

Based on observation, interview, and record review the facility failed to ensure three treatments were administered as ordered by the physician. This applies to 1 of 1 residents (R24) reviewed for physician orders [REDACTED]. The findings include: R24's Face Sheet showed an original admission date of [DATE] with [DIAGNOSES REDACTED]. On 10/14/20 at 12:10 PM R24 was in his wheelchair with pants and a long sleeved sweat shirt. He had several scabbed wounds to his knuckles on both of his hands. On 10/14/20 at 12:09 PM, V4 Registered Nurse stated the [MEDICATION NAME] is an antibiotic ointment for R24's scrapes he received after a fall. R24's TAR also showed an order for [REDACTED]. R24's TAR showed an order for [REDACTED]. On 10/14/2020 at 1:08 PM, V2 Director of Nursing stated after a treatment is completed the nurse should document the treatment as being completed. V2 said if the resident refuses or the nurse is unable to complete the treatment it should be documented. V2 stated the order for R24's toe is supposed to be done daily to protect the toe. V2 said if a treatment is not documented it was not done.

Based on observation, interview, and record review, the facility failed to provide activities to residents. This applies to 4 of 13 residents (R28, R19, R17, R40) reviewed for activities in the sample of 13, and 5 residents (R1, R13, R16, R34, R39) outside the sample The findings include: 1. R28's Minimum Data Set Assessment ((MDS) dated [DATE], shows R28 enjoys listening to music, keeping up with the news, and being around pets. The facility Activity calendar for 4/7/19, shows communion and family visits. No activities were planned after that. The activity board shows activity schedule for 4/5/19 (2 days ago). On 04/07/19 at 2:30 PM, 4:00 PM, and 6:00 PM, R28 was sitting in the couch by the main dining room looking around. There were no ongoing activities. R28 had no family visiting him. On 04/08/19 at 1:31 PM, V6 (Certified Nursing Assistant-CNA) said resident normally sits in the chair in the main dining room. V6 said she does not remember activities being offered on the weekends. On 04/09/19 at 9:03 AM, V4 (activity director), said there were no activities offered to residents on the evenings and weekends. V4 said she is the only activity staff in the facility. V4 said she feels bad that there were no weekends and evenings activities for the residents. V4 said activity is important in the life of the residents. Activities make residents cognitively aware of what's going on. Activities is a way of socializing, it keep everybody going. Activities can help with residents eye and hand coordination, like card games, trivias etc . and activities provide entertainment to the residents. R28's Care plan dated 9/18/18, shows R28 will maintain involvement in cognitive stimulation, social activities as desired. 2. On 04/07/19 at 2:30 PM, R1, R16, R39 and R40 were all seated around a table in the lounge with nothing on the table to do, and were just staring at each other. R17 was sitting at a table opening and closing her eyes. R34 was at a table all by herself, staring out the window not interacting with anyone. R19 was sleeping on the couch. No staff engaged or offered activities to the residents. These 7 residents remained in the same spot in the lounge until dinner was served at 6:00 PM (3.5 hours later). The facility's undated Activity Philosophy Objectives Policy shows The Department's major goal is to encourage and assist each resident to function at their optimal level in all dimensions of life-physical, psychological, intellectual and spiritual .To coordinate and direct a planned schedule of purposeful, interesting activities for residents of all skill levels. 3. On 4/8/19 at 10:30 AM, R13 stated there are no activities on the weekends. When asked what she does then, she said, I just sleep all day. It makes for a long weekend. R13's MDS dated [DATE] shows R13 is cognitively intact. R13's Care Plan revised on 8/13/18 shows R13 is very active in groups and enjoys independent recreation as well as leadership .R13's preferred activities are resident council president, table games, exercise, active games, outside, outing, and trivia.

Based on observation, interview, and record review the facility failed to safely transfer residents, and failed to ensure call light was within reach. This applies to 3 of 13 residents (R12, R17 R30) reviewed for safety in the sample of 13 The findings include: 1. R12's Minimum Data Set Assessment ((MDS) dated [DATE], shows R12 needs extensive assist of two or more staff for transfers and toileting. R12's fall risk assessment dated [DATE] shows R12 is high risk for falls. On 4/07/19 at 3:36 PM, V5 (Certified Nursing Assistant-CNA) was transferring R12 by herself via a mechanical stand lift to her bedside commode. R12 was saying I don't feel safe! .I don't like this! as R12 was trying to steady herself in the mechanical stand lift. On 4/8/19 at 8:30 AM, V10 (CNA) said R12 gets unsteady when being transferred with the mechanical stand lift and is in need of two (2) staff for safety. On 4/8/19 at 10:30 am, V3 (Registered Nurse-RN) said R12 is a bariatric (obese) resident. R12 is a two staff transfer using the mechanical lift. V3 said equipments can fail and it is not safe for one staff to transfer R12. R12's careplan dated 2/11/19 shows R12 is totally dependent on two staff for toilet use. R12 requires Mechanical Lift with two staff assistance for transfers. An undated facility policy entitled Safety in Transferring Resident shows any transfer requiring mechanical lift requires two staff. 2. On 04/07/19 at 02:40 PM, V7 CNA brought R17 to the shower room to use the toilet. V7, without using a gait belt, instructed R17 to grab the towel bar and instructed R17 to stand up. R17 pivoted and sat on the toilet. When R17 was finished, without placing a gait belt, V7 assisted R17 to grab the towel bar, stand up, pivot, and sit in her wheelchair. On 04/08/19 at 2:13 PM, V6 CNA stated I use a gait belt to help a resident to stand up when they are sitting on the couch, but if I'm toileting a resident I don't use a gait belt. I just assist them to stand and have them hold onto the towel bar. R17's MDS dated [DATE], shows R17 is cognitively impaired, requires extensive assist for transfers, and is not steady when transferring from seated to standing position and moving on and off toilet. R17's most recent Care Plan shows R17 is at risk for falls related to unsteady gait. The facility's undated Resident Handling Policy Limited-Lift shows, Gait belt usage is mandatory for all resident handling. 3. On 04/07/19 at 01:52 PM, R30 was asleep in bed. R30's call light cord was coiled around and hanging from the call light box on wall and not within R30's reach. On 04/07/19 at 04:30 PM, R30 remained in bed, with the call light in the same position on the wall. On 04/08/19 at 09:54 AM, R30 was in bed, and the call light cord was coiled around and hanging form the call light box on the wall, not within R30's reach. on 04/08/19 at 2:13 PM, V6 and V8 CNA said call lights should be on the resident or within the residents reach so they can call for help. R30's most recent Care Plan shows R30 is a high risk for falls and be sure R30's call light is within her reach. The facility's Answering the Call Light Policy dated (MONTH) 2010 shows When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview and record review the facility failed to provide measures to prevent the development of a pressure ulcer and failed to promptly initiate a treatment after the pressure ulcer was identified (R3). The facility failed to ensure that 2 resident's pressure ulcers were covered with a protective dressing. The facility failed to follow manufacturer's instructions for the use of a silver dressing. The facility failed to ensure that 2 residents with a known pressure ulcer had a pressure reducing cushion in her wheelchair (R3,R7). The facility failed to identify a pressure area on a resident's foot until the area was necrotic. The facility failed to ensure that a diabetic resident had properly fitting footwear. The facility failed to off-load pressure to the resident's once a pressure area was identified (R2).These failures resulted in R3 developing an unstageable pressure ulcer on his coccyx. This applies to 3 of 5 residents (R3, R2, R7) reviewed for pressure ulcers in the sample of 13. Findings include: 1. R3 is an [AGE] year old resident who was admitted to the nursing home on 2/27/11 with multiple [DIAGNOSES REDACTED]. R3 is wheelchair bound and requires extensive assistance from staff for bed mobility and transfers according to the Minimum Data Sets ((MDS) dated [DATE]. R3 did not have a pressure ulcer when he entered the facility but was identified as at risk for developing a pressure ulcer according to the MDS dated [DATE] and the Admission Nursing assessment dated [DATE]. R3 triggered for pressure ulcers on the Care Area Assessment (CAA) Summary but there was no skin prevention care plan in place per the MDS dated [DATE] and the complete care plan provided by E2 (Director of Nursing). R3 was identified at high risk for pressure ulcer development according the the pressure ulcer risk assessment dated [DATE] in the medical record. R3 developed a reddened area on his buttocks according to documentation on the Shower Skin Notification form dated 3/18/11. There was no documentation of skin checks following the identification of R3's reddened buttocks according to the nursing notes and treatment records. This was confirmed by E10 (Nurse) on 3/30/11. R3 developed an unstageable pressure ulcer on his left ischial measuring 0.6 by 0.6 cm according to the nursing notes dated 3/25/11. The note also documents that R3's buttocks were very excoriated. The physician's progress note dated 3/26/11 documents to apply santyl, cover with guaze and change daily. treatment of [REDACTED]. There is no other documentation in the medical record regarding initiation of treatment for [REDACTED]. This was confirmed by E10 on 3/30/11. The facility's Skin Care Protocol (not dated) documents that all dressing changes will be documented and initialed in the TAR. R3 did not have a dressing on his pressure ulcer prior to his treatment on 3/29/11 at 2:30 PM. This was confirmed by E10. R3 was observed up in his wheelchair on 3/28/11 from 12:17 to 12:40 PM and on 3/29/11 from 8:40 AM to 10:18 and 11:50 AM to 1:05 PM . R3's wheelchair cushion was two inverted egg crate cushions and was less than 3 inches thick. E10 confirmed that R3's cushion was not sufficient. 2. R7's March, 2011 POS documents that R7's [DIAGNOSES REDACTED]. R7's Pressure Ulcer Risk assessment dated ,[DATE] showed a score of 12 (8 or above represents High Risk). R7's MDS Assessment of 3/15/11 showed that R7 requires extensive assistance of one person for bed mobility, and transfer. The same assessment showed that R7 is occasionally incontinent of bowel and bladder. R7 had one unstageable pressure ulcer (covered with slough). R7's March, 2011 Treatment Administration Record showed an order to cleanse the wound on the Left Ischium, apply protective skin prep around the border, pack with Silverlon and cover. R7's Weekly Wound Management Tool dated 3/10/11 showed that R7's wound measurements were 1.6 cm (centimeters) x 1.4 cm x 1.5 cm. The same document showed that R7 had tunneling of 3.8 cm at 10:00 (clock wise location) and 3.1 cm at 11:00 o'clock, and 4.7cm at 12:00 o'clock. At 1:00 o'clock the wound tunneling was 2.4 cm and at 3:00 o'clock it was 5.1 cm, and at 5:00 o'clock it was tunneled 2.3 cm. (Tunneling is a channel that extends from any part of the wound through subcutaneous tissue or muscle. Tunneling can be documented by measuring depth and noting the location using the face of the clock as a guide.) Acute and Chronic Wounds, Third edition. Bryant and Nix, Mosby 2007, pg. 141. (The purpose of packing the wound is to fill dead space and avoid the potential of abscess formation by premature closure of the wound.) Acute and Chronic Wounds, Third edition. Bryant and Nix, Mosby 2007, pg. 421. On 3/29/11 at 1:45 PM E10 Registered Nurse (RN) was observed providing a treatment to R7's Left Ischium. R7 had no dressing/packing on her Left Ischial wound prior to E10's treatment. E10 confirmed that R7 should have had a treatment in place. E10 cleansed R7's wound and then packed the wound with a Silver rope product. (antimicrobial) E10 removed the rope from the package and packed R7's Ischial wound and then applied the cover dressing. The Silver rope product package showed that the rope should be moistened with sterile water prior to use. E10 said she was not aware of this. (had already packed R7's wound with the dry silver rope) R7's wheel chair cushion was observed on 3/29/11 at 1:45 PM and found to be a 2 inch foam cushion that was flattened down in the middle. E10 was present and made aware that R7's wheel chair cushion was bottomed out. 3. POS dated April 2011 shows that R2 has [DIAGNOSES REDACTED]. R2's Admission Nursing assessment dated [DATE] shows that R2 was admitted to the facility with slightly reddened heels. No other wounds are noted on R2's feet. The Nurse's Notes dated 2/22/11 state, "Noted on left foot outer aspect near toes a dark red/brown 1.7 x 1cm area that is hardened. No complaints with assessment. Skin is intact. Will monitor. MD notified of area on Left foot. E2 also notified and she said to keep pressure off of it and no shoes to be worn for now. Wound care nurse will be here on Thursday ( 2/24) to look." The NN dated 2/24/11 state, "Dark are noted on the ball portion of the left foot. 2nd toes on left foot is also dark around the nail area..." No documentation regarding R2's left foot prior to the areas being found as dark red/brown and hardened could be found in R2's medical record. R2's Pressure Ulcer Risk assessment dated [DATE] shows that R2 scored a 13 (8 or above represents High Risk). The Wound Care Report dated 2/24/11 shows that the consulting wound care agency recommended that R2 wear a heel suspension boot on his left foot. On 3/29/11 at 10:30 AM, R2 stated, "My heels itch. My left foot has been itching and now the right one is starting to itch too." R2 was then observed as he transferred from the bed to the wheelchair wearing his shoes. On 3/30/11 at 11:15 AM, E10 (RN) stated, " They (foot wounds) developed here. Probably from his shoes due to the nature of it. " E10 was asked if R2 was supposed to be wearing his shoes and E10 replied, "Yes, they were made special for him." R2's careplan dated 2/15/11 states, "To wear shoes only for therapy." On 3/29/11 at 2:30 PM, R2 complained of not having a pillow to put under his feet. R2 continued to complain that even the blankets hurt his toes as they are "too tight." R2's family, present during this observation stated that R2's shoes were made by a community podiatrist over a year ago and that they probably should make him another appointment. The facility's undated Protocol for Skin Care states, "Assess resident's heels carefully for [DIAGNOSES REDACTED]. Residents with impaired mobility or who are completely immobile are at an extremely high risk for heel breakdown. elevate heels off mattress and support calves and ankles with a pillow."